Provider Demographics
NPI:1730203506
Name:WAKE FOREST HEALTH NETWORK LLC
Entity type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP NETWORK PHYS & HS CMO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARS
Authorized Official - Last Name:HOWERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-716-1331
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:10188 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2906
Practice Address - Country:US
Practice Address - Phone:336-802-2070
Practice Address - Fax:336-802-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1212660021OtherDME
NC5908889Medicaid
NCCC4243OtherRR MEDICARE
NC0247KOtherBCBS
NCCC4241OtherRR MEDICARE
NCD266OtherPARTNERS
NC25220OtherMEDCOST
NC890247KMedicaid
NCCD6614OtherRR MEDICARE
NC7584779OtherAETNA
NCCB8658OtherRR MEDICARE
NCCB8658OtherRR MEDICARE
NCCB8658OtherRR MEDICARE
NC2318873AMedicare PIN